MMIS Report Joint Appropriations Subcommittee on …€¦ · MMIS Report Joint Appropriations...

MMIS Report Joint Appropriations

Subcommittee on Health and Human Services

March 14, 2013

Ed Riley

Associate Program Director

Contract Manager

NC DHHS Office of MMIS Services

Paul Guthery

Associate Program Director

Senior Program Manager

NC DHHS Office of MMIS Services

NCMMIS Program Purpose Replacement MMIS Project (NCTracks)

◦ Design, develop and install a componentized, integrated, multi-payer Replacement Medicaid Management Information System (MMIS) and Fiscal Agent operations

◦ Facilitate provider enrollment and consolidate claims processing activities for multiple DHHS health plans Division of Medical Assistance – Medicaid & Health Choice Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Division of Public Health Office of Rural Health and Community Care

◦ Coordinate processing among the payers to ensure the proper assignment of the payer, benefit plan, and pricing methodology for each service on a claim

3/14/2013 2 MMIS Report - Joint Appropriations Subcommittee on Health and Human Services

NCMMIS Program Purpose Reporting & Analytics Project

◦ Design, develop and install a state-of-the-art Data Warehouse, and reporting solution that meets not only current DHHS needs, but provides a platform for changes leading to future growth with enhanced self-service by the end-user community

◦ Surveillance Utilization Review System (SURS) – Detection of fraud and abuse

◦ Decision Support System (DSS) – Healthcare data analytics to empower more informed policy decisions


NCMMIS Program Purpose Business Process Automation System Project

◦ Identify and execute the procurement and implementation of a Business Process Automation System and associated business services for the DHHS Division of Health Service Regulation (DHSR)

◦ Satisfy the information sharing requirements with the Replacement MMIS in the area of provider eligibility

◦ Provide automation, using a common database, to support the business functions of DHSR

Certificate of Need

Construction

Licensure and Certification

Health Care Personnel Registry

Center for Aide Regulation and Education


Advantages of the Replacement MMIS Multi-payer system consolidating claims processing for multiple

DHHS divisions, ensuring the proper assignment of payer, health plan, benefit plan, and pricing methodology for each claim line

Provider Web Portal ◦ Provider Enrollment

◦ Changes to Provider enrollment information

◦ Recipient Enrollment and Service Limits

◦ Electronic Claims Submission

◦ Fee Schedules and Rates

◦ Prior Approval Inquiry and Request

◦ Claims Status Information

◦ Retrieval of Remittance Advices

◦ Online access to training information


Advantages of the Replacement MMIS Recipient Web Portal

◦ Online access to health care coverage information

◦ Administrative contact information for benefit plans including managed care organizations

◦ Health Plan and Benefit Plan name and coverage dates

Claims Processing ◦ Multi-detail, multi-payer claims submission

◦ Outpatient hospital claims at a line item detail level for all revenue codes

◦ Automated claims adjustments

◦ Immediate adjudication of claims


MMIS Legacy System Synchronization Modifications to the legacy solutions continued after the system

freeze date

Limitations to the level of change that can be made to the system once final testing began while maintaining quality ◦ System soft freeze began on March 2, 2012 – Hard freeze began on May 31, 2012

◦ User Acceptance Testing (UAT) began August 29, 2012

◦ Changes approved after freeze date not available for current UAT


MMIS Legacy System Synchronization CSC Contract Amendment #3 created to allow for the development

and testing of the most critical of these changes ◦ Additional capacity for change allocated

◦ Move Operational Readiness Date from March 1, 2013 to July 1, 2013 to accommodate additional Medicaid changes

◦ Maintain July 1, 2013 Operational Start

◦ Use capacity originally allocated to ICD-10 (International Classification of Diseases 10th

Revision)

Federally required compliance date moved from October 1, 2013 to October 1, 2014

Work continues on ICD-10 in preparation for system changes

◦ Additional Final Integration and User Acceptance Testing Period

April / May 2013

Overlap additional testing with the execution of Provider Operational Preparedness (POP)


MMIS Legacy System Synchronization Additional Synchronization Gap Less Critical Functionality

◦ Additional CSRs are currently in the CSC backlog to be implemented that will not be addressed by July 1, 2013

◦ The first two post operational start software releases are scheduled for:

October 1, 2013

January 1, 2014

◦ Workarounds required until the implementation of functionality


Workarounds Strategy Workgroup currently developing workarounds for 288 change

requests ◦ 120 Customer Service Requests (CSRs)

◦ 168 State Memoranda

The workaround strategies can be broadly grouped by the following categories:

Change policy, business rules, and/or claims filing instructions

Manual intervention performed by CSC, the State, or other vendor

Pay and chase or report

Monitor impacts

Cancel original change request

Suspend specific task in Division operations

Workgroup to complete identification of workarounds by March 18

Work beginning to define impacts and communications


Replacement MMIS Schedule

System Hard Freeze

Items added or extended ffected by Contract Amendment 3 shown in crosshatched shading

Fiscal Agent Operations

Sep Oct Nov Dec

2012

Feb Mar Apr May Jun Jul Aug

2013

JulJan Sep Oct Nov Dec

Additional UAT

Aug

PST Extended

UAT Extended

Mar Apr May JunFeb Nov Dec

2014

May Jun Jul Aug Sep OctJan Feb Mar Apr

Target for 2nd Release

Target for 1st Release

Build System Integration Testing

Additional Final Integration

Test (FIT) / PST

Provider Operational

Preparedness

UAT for

Providers

Production Simulation Testing

(PST)

User Build Acceptance Test (UBAT)

System Soft Freeze

FIT

FSIT

User Acceptance Testing

BSIT

CMS Certification


User Acceptance Test (UAT) Results User Acceptance Test Cases Completed by the State: 1,980

Test Cases with no outstanding defects: 1,751 (88.4%)

Total defects discovered during UAT: 1,520 ◦ Initial UAT period (8/29/2012 – 1/16/2013)

Severity Exit Threshold

Discovered Resolved Open

1. System-wide Failure 0 33 33 0

2. Inconsistent Results 10% (83) 839 761 78

3. Workaround Exists 25% (134) 537 452 85

4. Cosmetic n/a 96 51 45

5. Working as Designed n/a 15 1 14

Total n/a 1,520 1,298 222


Overall Program Budget


Vendor Cost Savings - MMIS Over the five year operations & maintenance phase, the CSC

contract cost will save on average $3 million per month over expected future costs of existing contracts that will be retired when NCTracks is implemented.

The state appropriations savings over that same five year period is expected to average over $900,000 per month.

Systems to be retired by NCTracks: ◦ MMIS – HP

◦ IPRS – HP

◦ Pharmacy Prior Authorization Call Center – Xerox

◦ Smart PA – Xerox

◦ POMCS– DHHS


CSC Contract - MMIS

Vendor Amendment Cost State Share

CSC

Development1 Base 77,960,715$ 9,901,010.81$

Ops & Maintenance Base 187,243,759$ 51,023,924.33$

Development Amend # 1 -$ -$

Ops & Maintenance Amend # 1 -$ -$

Development Amend # 2 152,754,523$ 18,025,033.71$

Ops & Maintenance2 Amend # 2 66,921,800$ 18,236,190.50$

Development Amend # 3 N/A N/A

Ops & Maintenance Amend # 3 N/A N/A

Total

Development 230,715,238$ 27,926,045$

Ops & Maintenance 254,165,559$ 69,260,115$

NCMMIS+ ProgramContract Amendments

1 Although not included in the initial contract; $ 22M was budgeted for changes

and approved by CMS. 2 Two additional years of operations were added to the contact.


Program Risks and Issues Based on analysis by an outside consultant, Susan Young, the following risks and

mitigation strategies have been identified:

Risk Mitigation Strategy

Stakeholder Engagement A supplementary communications approach has been developed and a resource allocated to integrate the specific plans into the overall program and management routines

Program Planning, Execution and Monitoring

The MMIS Program has now been aligned under the DHHS CIO, and availability of critical resources has been secured

Organizational Change Enablement

An external consultant will be engaged to drive our development of Division business processes and facilitate additional preparations for user testing and transition

Change Management A hard freeze has been placed on further changes to the legacy and new systems. A team has been formed to identify gaps and define interim processes

Overall Implementation Strategy

Resources will be reallocated to support deployment planning efforts and bring focus to the most significant levers for the success of the initiative.

Test Planning and Execution Critical resources to support testing cycles have been secured. Additional business process activities will make user testing and readiness assessments more effective


Program Risks and Issues As reported by CSC in their 2/14/2013 report to the NCMMIS+ Steering Committee

Risk Mitigation Strategy

Provider Conversion A number of data quality issues have been identified during PST and UAT that impact claims adjudication. The State and CSC have made good progress. 2 outstanding issues remain, 3 issues require data clean up and one potential workaround has been identified

Taxonomy The current design requires a taxonomy at level 3 for professional providers and some may have credentials only to a level 2. CSC has determined the effort required to make the required modifications and will work with the State to determine how to implement by operational start.

Interfaces CSC is still working through interface files from the State so end to end testing can occur during the extended PST. 8 interfaces will be tested during the May PST.

Legacy CSR Workarounds There are approximately 120 Legacy CSRs and 168 State memoranda that will not be in NC Tracks at operational start. OMMISS and DMA are evaluating the workarounds with a 3/18/2013 completion target. Any impact to CSC operations must be reviewed and determined after that date.


Appendix

3/14/2013 MMIS Report - Joint Appropriations Subcommittee on Health and Human Services 18

CMS Certification Review of the MMIS and operations

◦ CMS Certification Checklists

State requests certification after the closeout of two fiscal quarters ◦ Operational start on July 1, 2013

◦ North Carolina can request certification after closing out the quarter ending December 31, 2013

Following the request, CMS and the State begin planning one week on-site certification review ◦ Document collection and preparation

One week on-site visit typically at least one year after operational start

Based on the information collected, CMS may issue findings and require the State to take remedial action


CMS Certification Financial Impact

◦ On the first day of operations, the Federal match for operations is 50%

◦ Upon certification the Federal match for operations improves to 75%

◦ When certification is achieved, the difference between the 50% and 75% Federal match is paid retroactively back to the day the system is deemed by CMS to be the system of record


Testing Participation CSC Staff

◦ Build System Integration Testing

◦ Final Integration Testing

◦ Final System Integration Testing

◦ Production Simulation Testing

OMMISS Staff ◦ User Build Acceptance Testing

◦ User Acceptance Testing

◦ Review of CSC Conducted Testing

Division Testing ◦ 46 participants from the DHHS divisions

◦ Participants from DMA, DMH/DD/SAS, DPH


Testing Participation Providers

◦ User Acceptance Testing for Providers

◦ Worked with 25 Provider Associations for nominees

◦ 37 Providers nominated by 8 associations participated over six weeks


Transition Planning Deployment Planning Approach

Iteration Content

Initial Framework (Delivered 11/26/2012)

Establishes the concept, structure, and layout of the deliverable, with a focus on the introductory information, high-level activity/task and schedule definition, establishment of assumptions and constraints, templates and integration with related documents.

Iteration 2 (Delivered 2/15/2013)

Focuses on the detailed rollout and deployment schedule/activities, post deployment activities, organization rolls and responsibilities, continued refinement of assumptions and constraints, populating the templates, and details of the back out plan.

Iteration 3 (Delivery 3/31/2013)

Continued expansion of the detailed rollout and deployment schedule/activities, expansion of the post deployment activities, finalization of the organization rolls and responsibilities, continued refinement of assumptions and constraints, continued refinement of the back out plan details.

Final Iteration (Delivery 5/31/2013)

Wrap-up of the detailed rollout and deployment schedule/activities, wrap-up of the post deployment activities, wrap-up of assumptions and constraints, wrap-up of the back out plan details.


Budget Update Overall Program Budget and Budget for Each Project

◦ Initial

◦ Current

◦ Reasons for Changes

◦ Operations and Maintenance Costs

◦ Sources of Funding


Replacement MMIS Budget


Reason for Changes to the Replacement MMIS Budget 1. Schedule slipped 22 months; functionality has been added.

Reasons for slippage: • Over estimation of the degree of fit with the baseline solution from CSC

• Estimated 73% reuse – Realized 32% reuse

• Approximately 200 legacy change requests that were not included in the original scope were added to the design

• Federal Scope Expansion:

• HIPAA 5010

• ICD-10

• National Correct Coding Initiative (NCCI)

• Healthcare Reform

• State Legislation: SL 2010 and SL 2011 changes

• Added four months of Provider Operational Preparedness


Reason for Changes to the Replacement MMIS Budget 2. Added 22 months to the development phase impacting the

Independent Verification and Validation (IV&V) and Testing vendors’ contracts; and internal labor and project support costs

3. Revised estimate of the resources needed to manage vendors and to begin the next MMIS procurement cycle

4. Added 22 months to early operations (provider enrollment, credentialing and verification) and for drug utilization review; also realized a larger number of providers enrolling in Medicaid


Reporting & Analytics Budget


Reason for Changes to the Reporting & Analytics Budget 1. Due to the MMIS project being extended 22 months, the R&A

project needed to be extended as R&A is dependent upon data from the Replacement MMIS. Also developed and implemented the Surveillance Utilization Review System (SURS) to operate with legacy data

2. Added 22 months to the development phase impacting IV&V and Testing vendor contracts

3. Although the development phase was extended, the staffing level required to support this R&A project was initially overestimated


Business Process Automation System (BPAS) Budget

Initial Current Reason Federal State Share

Development 6,167,739$ 8,565,102$ 4,697,413$ 3,780,389$

Vendor Costs

GLS 4,205,970$ 4,205,970$ 2,102,985$ 2,102,985$

IV&V and Testing 174,601$ 174,601$ 87,301$ 87,301$

Internal Costs 1,787,168$ 4,184,531$ 1 2,507,127$ 1,677,404$

Ops & Maintenance 6,119,699$ 8,119,699$ -$ 8,119,699$

Vendor Costs 4,846,779$ 4,846,779$ -$ 4,846,779$

Internal Costs 1,272,920$ 3,272,920$ 1 -$ 3,272,920$

Total 12,287,438$ 16,684,801$ 4,697,413$ 11,900,088$

Business Process Automation System (BPAS) Project

Budget


Reason for Changes to the BPAS Budget 1. Staffing levels were initially underestimated and required

hardware and software was omitted from the initial budget


Program Level Project

Initial Current Reason Federal State Share

Development 9,721,297$ 15,803,746$ 13,828,278$ 1,975,468$

Vendor Costs -$

Internal Costs 9,721,297$ 15,803,746$ 1 13,828,278$ 1,975,468$

Certification 1,430,271$ 2,440,790$ 2,135,691$ 305,099$

Vendor Costs -$ -$ -$ -$

Internal Costs 1,430,271$ 2,440,790$ 2 2,135,691$ 305,099$

Total 11,151,568$ 18,244,536$ 15,963,969$ 2,280,567$

Program-Level Project

Budget


Reason for Changes to the Program-Level Budget 1. The project length was extended by 22 months, additional staffing

hours were required due to the extended schedule

2. Updated staffing requirements for the first year of operations to support maintenance and federal certification activities


Contract Amendments

Contract Amendments ◦ By Project and vendor

◦ Cost Increase associated with each


Truven Contract – Reporting & Analytics


Truven

Development Base 6,877,113$ 687,711$

Ops & Maintenance Base 43,428,927$ 10,857,232$



Development CSR 787 1,511,370$ 151,137$

Development Amend # 2 1,441,798$ 1,297,618$

Ops & Maintenance Amend # 2 20,851,305$ 5,212,826$



Total

Development 9,830,281$ 2,136,467$

Ops & Maintenance 64,280,232$ 16,070,058$



GLS Contract – Business Process Automation System (BPAS)


GLS

Development Base 5,515,494$ 2,757,747$

Ops & Maintenance Base 3,537,255$ 1,768,628$



Total

Development 5,515,494$ 2,757,747$

Ops & Maintenance 3,537,255$ 1,768,628$



Maximus Contract – Independent Verification and Validation (IV&V)


Maximus


Ops & Maintenance Base 378,796$ 94,699$



Development Amend # 2 1,459,752$ 153,274$

Ops & Maintenance Amend # 2 507,640$ 126,910$

Total

Development 4,009,720$ 421,021$

Ops & Maintenance 886,436$ 221,609$



SLI Contract - Testing


SLI


Ops & Maintenance Base 2,081,113$ 520,278$

Development Amend # 1 3,575,996$ 364,752$

Ops & Maintenance Amend # 1 (1,934,887)$ (483,722)$

Total

Development 7,094,298$ 723,618$

Ops & Maintenance 146,226$ 36,557$



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